Response to diagnosis of appendicitis.

To the Editor: The article by Mathis et al (1) in SMJ in December 2005 reports 150 cases seen by emergency department physicians with a "discharge diagnosis of appendicitis." Flaws in their study serve to negate the conclusions drawn. They acknowledge that the retrospective study had a bias associated with a higher complication rate occurring when the NCT (no CT) patients were taken to surgery sooner than those having a CT that were less ill. The study also failed to specify if a surgeon was involved in the decision to order a CT scan. Furthermore, they commented upon the "inherent limitations" of their study when relying on chart documentation. The ordering of in-house radiological tests by hospital-affiliated attending physicians, such as in the ER, is a further unnoted bias consideration.

The nature of the final diagnosis criteria for appendicitis remains unspecified in this study. Is their "discharge diagnosis of appendicitis" clinically or pathologically based? It might be assumed that hospital records reflect a pathology diagnosis, yet surgeons are aware of the fact that this can vary by individual technique and evaluation of appendiceal studies. Particularly significant is the rejection of a diagnosis of appendicitis formerly recognized as "chronic," (2) which is a clinical entity. Such a condition, oftentimes with recurrent abdominal pain, may reveal little microscopic bacterial inflammatory response, but may occur with viral or allergic disorders. The incidence of complications from a lymphoid infiltrated appendix is far less than with obstructive disease or a delayed diagnosis. In a study of intra-abdominal lymphoid hyperplasia, (3) the appendix was appropriately recognized as the "tonsil of the abdomen." Many pathologists do not consider the intense lymphoid hyperplasia (4) that produces appendiceal and mesenteric swelling with classic clinical symptoms of appendicitis. This is because such conditions are not reflected in a microscopic bacterial inflammatory response. These inconsistencies affecting a final diagnosis exist when an appendix is removed for clinical symptoms but does not present the above response. Abdominal pain of an appendiceal type may be due to malignancy, (5) carcinoids (6) and oxyuriasis which appear to be omitted from the study. This further invalidates their "diagnosis of appendicitis" study that concludes:

"Contrary to our initial hypothesis, no increased incidence of appendiceal perforation or abscess was demonstrated based on ED physician's decision to perform CT without surgical consultation."

The SMJ article to me epitomizes the state of medical/surgical practice today. Too much or too little science is the question. The era of clinical surgery through which I lived had its share of misdiagnoses and errors, just as today. Now urgency of early surgery in acute, especially obstructive, appendiceal disease has been dulled with the advent of powerful antibiotics. But make no mistake, the complications of delayed appendectomy can be serious, with morbidity (7) and lifelong consequences, and even fatalities. This is true both for acute symptoms related to obstructive inflammation or other appendiceal pathology.

Both editorials in the same SMJ issue need re-emphasizing when Naoum (8) comments that "The era of clinical diagnosis of appendicitis has not come to an end...." In the other editorial, Liang (9) states "All patients with acute abdominal pain should be seen by a surgeon who then may or may not recommend a CT scan."

This era of too much science versus too little does come into question. However, the bias toward increased science to avoid litigation and to enhance one's own or a hospital's income is a dangerous precedent physicians need to avoid. Rising health care costs and the tendency toward litigation are powerful forces leading to dangerous social and political actions. These forces must be harnessed and can be done so only by conscientious patients and competent, honest healthcare providers without misleading sensational reporting. Otherwise both groups will be disadvantaged.

Gerald N. Weiss, MD

Fort Collins, CO

References

1. Mathis RD, Chiumento AB, Yeh B, et al. An outcome study of the use of computed tomography for the diagnosis of appendicitis in a community-based emergency department. South Med J 2005;98:1169-1172.

2. Weiss GN. The changing picture in appendiceal disease: a fifteen year survey at Touro Infirmary. New Orleans Med Surg J 1950;102:542-549.

3. Weiss GN, Ranier A. Intra-abdominal lymphoid hyperplasia and appendiceal disease: clinical and pathological analysis of 100 consecutive series. South Med J 1960;53:7-11.

4. Weiss GN, Ranier A. Intra-abdominal lymphoid hyperplasia and appendiceal disease. Am Surg 1961;27:706-710.

5. Weiss GN. Mucinous peritonitis of appendiceal origin: benign or malignant? J Abd Surg 1960;2:128-131.

6. Weiss GN. Hertzog AJ. Carcinoid tumors of the appendix: a review of 26 cases. Surgery 1951;30:657-660.

7. Holder AR. Misdiagnosis of appendicitis: law and medicine. JAMA 1970;212:1763-1764.

8. Naoum JJ. Do all patients with suspected appendicitis benefit from CT imaging in community-based emergency departments? South Med J 2005;98:1157-1158.

9. Liang MK. The art and science of diagnosing acute appendicitis. South Med J 2005;98:1159-1160.